The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on interview and record review, the facility failed to protect patients by ensuring staff followed established procedures prior to issuing identification badges to non-employed persons seeking to observe within patient care areas of the hospital.

Findings included:

1. On or about 08/01/2011 an applicant, [AGE] and unknown to the hospital, requested observation privileges in the patient care areas of the hospital. This person turned in a checklist (downloadable from the Internet) with his own signature in place of the representing sponsoring physician. The physician signature was never verified.
2. During a conference on 09/26/2011 at 11:30 a.m. the Human Resources (HR) Director said the unknown applicant did get a badge on 08/01/2011. It was a badge for observership to be used with a physician known to the hospital (sponsor). The badge was returned by law enforcement on 09/06/2011.
The HR Director said the hospital investigation showed the HR personnel did not verify the signature. The signature was not the physician, but was actually the unknown applicant's own signature, and HR issued the badge at the Kissimmee campus. During a phone interview on 09/26/2011 at 11:50 a.m. the Human Resources Compliance Manager said there is nothing in the policy that requires verification of identity or verification by the physician.

3. Review of a copy of the badge obtained by the unknown person showed the following:
Name: Unknown person ' s name
FH Contact name: Osceola Surgical Associate
Phone: 407-xxx-xxxx
Campus: Nova University
Department manager/sponsor: Known hospital physician
Start Date: 08/03/2011 Duration 09/03/2011

4. Review of the Policy Standard Operating Policy, dated 04/2011, showed the policy does not require any special verification prior to the issuing of a badge to an observer.

5. Review of the checklist form, dated 04/2011, showed the following as required:
Florida Hospital
Standard Operating Procedure for Job Shadowing/Observation at Florida Hospital
Version date 04/2011
Enclosed you will find:
Observation process checklist
Observation Process Flow
HIPAA Compliance Fact Sheet
HIPAA Compliance Fact sheet sign-off form
Release of Liability Consent to Participate in Observation at FH

Items 1 and 2 on checklist must be dated, initialed, and signed off by the Sponsor/FH Department Manager and presented to Campus HR Office prior to assignment.
Campus HR Department will then issue FH Temporary ID badge.
Key Points: Applicant must be 18 years or older

6. Review of the checklist showed the unknown person filled out the form as follows:
Staff Name: name
Contact Name: Osceola Surgical Assoc.
Phone Number: 407-xxx-xxxx (the phone number was tried and it does not appear to be a business phone number).
Campus: Nova University
Start date: 08/3/2011 Duration: 09/03/2011
1. Request to Observe-signed by the applicant
2. Release of Liability-signed by the applicant
3. HR Process-signed by the applicant
4. Department Orientation-signed by the applicant
5. Observation Completion are all dated [DATE] and initialed with the applicant's initials and not the sponsors.
The signature area is signed as follows:
Observer Name: the applicant
Signature- applicant (unknown person) and dated 08/01/2011
FH Dept. Manager/Sponsor Name: known hospital physician, MD
Signature: by the applicant and not the physician and dated 08/01/2011

7. During an interview on 09/27/2011 at 12:30 p.m. the director of HR and the HR Compliance Manager both confirmed the Checklist form is not signed off on by any department manager and/or the sponsor as required.
The Human Resources Compliance Manager said there is no application on file, because the unknown applicant would have been able to download the checklist off the Internet and because the physician was very well known to the facility the observation was granted. She also said the process is being changed in order to keep patients safe on the hospital campus.
On 09/27/2011 at 12:30 p.m. the assistant administrator said it was clearly a broken process, the HR employee did not follow the procedure.